Abstract In the United States alone, more than three million peripherally inserted central catheters (PICCs) are placed each year to provide IV therapies, where navigation through the venous system is typically performed blind, or without navigation guidance. Improper PICC placement is relatively common, is costly, and has serious complications for critically-ill patients. Unfortunately, under blind placement 30-55% of PICC tips are not optimally placed on the first attempt and require repositioning, which has an average direct cost of $223 per patient and often necessitates the removal and reinsertion of the catheter line that carries a 4-6% risk of pneumothorax. Moreover, approximately 17% of these improperly positioned PICCs are placed into the right atrium, which is associated with a multitude of life-threatening complications. Improper placement of PICCs also often requires referral to an interventional radiologist for fluoroscopic-guided central line placement, which is expensive ($1,000) and requires more radiation exposure for the patient. Not surprisingly, over half of all PICCs are administered to patients over the age of 60. Therefore, safe and accurate PICC placement is critical for providing high-quality care to older Americans. Despite serious adverse events associated with blind placement of PICC lines, current vascular access systems have not been widely adopted. The Teleflex ARROW G4 VPS and the Bard Sherlock 3CG TCS are PICC guidance systems that employ ECG for positioning the PICC tip into the correct location: the region that includes the lower superior vena cava (SVC) and cavoatrial junction (CAJ). While these procedures often limit the need for a confirmatory X-ray, they have poor and variable successful placement rates (44-84%), are 30-70% more expensive than standard PICCs, require skilled staff, and have significantly longer procedure times as compared to standard, blind PICC placement. Additionally, these guidance systems rely on the use of ECG, which is ineffective for patients with cardiac arrhythmias, a condition that affects approximately 16% of all patients requiring a PICC line. To address the need for accurate, safe, and cost- effective PICC placement, Piccolo Medical has developed the Smart PICC? system, a point-of-care catheter system that uses unique hemodynamic signatures of different vascular regions for real-time vascular access guidance into the SVC/CAJ. The goals of this Phase II proposal are to validate the accuracy of the Piccolo Smart PICC? for navigation and placement of a PICC tip into the SVC or CAJ for adult patients with and without cardiac arrhythmias. First, we will verify the sensitivity of the Smart PICC? system algorithm to identify correct PICC placement in adult patients with both normal and altered cardiac rhythms (Aim 1). Second, we will compare the accuracy of the Smart PICC? system to the most widely used catheter navigation system (BD?s Sherlock 3CG TCS) in a head-to-head superiority study (Aim 2).The data obtained will support FDA 510(k) clearance and will allow us to commercialize the system within ~2.5 years of the funding of this proposal.